PROMISEPerformance Reporting and Outcomes
Measurement to Improve the Standard of care at End-of-life
The PROMISE team
How well are we doing?
“Our facility delivers the best possible end-of-life care.”
“Our palliative care team has a significant impact on the care of veterans.”
“Veterans who die in our hospice unit get much better care that they would elsewhere.”
How do you know?
You don’t know
“ When hearing something unusual, do not pre-emptively reject it, for that would be folly. Indeed, horrible things may be true, and familiar and praised things may prove to be lies. Truth is truth unto itself, not because people say it is.”
-Ibn al-Nafis
“In God we trust. All others must measure outcomes.”
-Anonymous
PROMISE: Measuring successes and identifying opportunities
To identify and reduce unwanted variation in the quality of end-of-life care for veterans.
To define and disseminate processes of care that contribute to improved outcomes for veterans near the end of life and their families.
Objectives:
To introduce the PROMISE centerTo explain PROMISE:
» Methods» Reports
To describe where PROMISE is going; andTo identify ways in which we’ll need your help
What is PROMISE?
The quality measurement center for the VA’s CELC Initiative
Based at the Philadelphia VAMC Center for Health Equity Research and Promotion
Funding through CELC for:» A voice for veterans/families» Actionable data that can guide
facility- VISN- and national-level planning and strategy.
Meet the PROMISE Team
Dawn Kim Monica Jennie Matt Sean Tiffany
Hien Megan Fiona Maysa Katie Anushree Christine
Nicole Elena Wei Charlotte Daisy Joan
What does PROMISE deliver?
Data for facilities about the quality of end-of-life care they provide» Timely feedback» Understandable reports» Meaningful benchmarks
Practical guidance for HPC programsUseful evaluations for CELC Initiative
leadership
Framework for PROMISE data: Domains of care (from NCP guidelines)
Physical aspects of careSocial aspects of careSpiritual, religious, and existential aspects
of careCultural aspects of care Care of the imminently dying patientPsychological and psychiatric aspects of
care (including bereavement)
Framework for PROMISE data: Aspects of care
Outcomes (Families’ perceptions of care)
Processes of care (from chart reviews)
Currently (Q4 FY09) 96 facilities:» ~5800 interviews» ~11,000 chart reviews
Step #1: Chart review
Deaths identified by Program Managers using VISN data (multiple overlapping samples)
The PROMISE sample:» We identify inpatient deaths» We exclude “unexpected” deaths (e.g. ER,
suicide, homicide, OR for outpatient procedure)
Remote chart reviews via Global CPRS
Step #2: Outcomes of care (The Bereaved Family Survey)
BFS: OMB-approved survey derived from the Family Assessment of Treatment at End-of-life (FATE)
14-item telephone survey administered to the veteran’s NOK 6-10 weeks after death
Procedure:» Predefined algorithm for contacts (NOK first choice)» Initial letter with opt-out provision» Telephone contact» Opportunity for family members to refer to alternate
Outcomes of care: BFS scoring
All items are either dichotomous or frequency-based» Did you receive as much help as you needed with…
» How often did the health care providers who took care of [veteran]…
Responses dichotomized (Best possible response vs. all others).
BFS and item scores reflect a proportion of the time that the veteran/family received the best possible care.
Overall BFS scores
Individual items: (Bereavement support)
Step #2: Processes of care from chart review: (examples)
Pain assessment in the last 24 hours of last admission
Palliative care consultation noteDocumentation of a surrogate or that a
surrogate could not be foundChaplain contact with veteran/familySocial work noteDocumentation of a bereavement contact
within 2 weeks after death
Processes of care: Documentation of a bereavement contact
How do we use process of care data?
Not performance measuresProcess of care data give diagnostic tools that can:
» Identify potential problems» Find opportunities for improvement» Guide improvement strategies
Process of care data give evidence of impact that can:» Demonstrate the value of what you do» Help to justify (continued) funding
Using process of care data as a diagnostic tool
Example: Families at facility X feel they didn’t get enough bereavement support.
Ask:» Are we contacting families? » Or maybe the PCCT is contacting families, but
other providers aren’t?
Pitfalls of using process of care data as a diagnostic tool
But:» “We make all our calls at 1 month”» “We document our calls in a collateral note”» “We don’t have time to document our calls”
Only you can decide whether a process measure is useful in your facility.
Using process of care data to show impact: One facility’s example
Good: “We were able to offer bereavement support to 60% of families of veterans who died as inpatients.”
Better: “Those contacts resulted in a 17-point increase on our facility’s bereavement score.”
Best: “Those contacts resulted in a 17-point increase in our facility’s bereavement score, compared to a national average 10-point increase.”
Getting data from PROMISE
Reports:» BFS data (outcome measures)» Chart review data (process measures)» Open-ended responses
More data…
Quarterly VISN-level reports
De-identified reports broken down by facilityAvailable at the end of the next quarter (Q1
deaths reported at the end of Q2)Compared to a goal (pooled mean of top
facilities)Hypertext links to:
» Success Stories on PROMISE website» SharePoint tools (Luhrs)
Additional data…responses to 2 open-ended questions
“The hospice unit was the best part of the care that [veteran] got in the whole 14 years that he was going to the VA.”
“We really depended on the palliative team—they were wonderful.”
“Everyone was very helpful, but especially [NP on PCCT]. She was always there, always available. We wouldn’t have made it without her.”
Additional data…referrals for unmet needs
Unmet needs identified in interviews:» Bereavement
» Questions about care
» Questions about benefits
Referred to VISN coordinator and/or facility patient advocate (with family permission).
Gives us:» An opportunity to meet needs and to leave families with
a good impression of the VA
» Valuable data about needs for improvement
Can you give us even more data?
Additional data…
Aggregate (broken down) data available to each VISN
“Raw” data available on requestMenu-driven custom reports online (to be at
the PROMISE website)» “Mean BFS score in our ICU, with and without
palliative care”» “Mean bereavement score in our VISN, with and
without a bereavement contact”
VISN “Hotseat calls”
Opportunity to get immediate answers to data questions:» What effect is our chaplain having on families’
perceptions of spiritual support?» What is the impact of palliative care in facility X?» What is the value of a hospice unit in facility Y?
Using the PROMISE report: 6 rules
1. Don’t panic
2. Focus! (Look at individual items)
3. Ask: Do you have enough data? (Often two quarters’ worth)
4. Use common sense (does this score make sense?)
5. Select one item to improve that has:1. A low score
2. An obvious action plan
6. Be skeptical about changes
Closing the loop: Bringing the veteran’s and family’s voice back to
the bedside
Help us close the loop (1-2)
1. “Success stories” disseminated on the PROMISE website and in monthly e-newsletter» Structured description via web-based form (through PROMISE
website)» We need descriptions of:
• Good scores• Improvements• How you’re using PROMISE data
2. “QI Registry” tracking single-facility interventions» Structured description of goal, intervention, and expected
outcome submitted via web-based form (Through PROMISE website)
Help us close the loop (3)
3. “QI Collaboratives” that track multiple-facility interventions» Best Practices reviewed/selected by advisory panels
(Carol Luhrs and Therese Cortez)» Designated leader» Organized schedule» Technical assistance from the Implementation
Center» Measurement/analysis by the PROMISE Center» Tailored feedback
PROMISE Implementation
Guidelines/ Expert opinion
PROMISE goals:
To identify and reduce unwanted variation in the quality of end-of-life care for veterans.
To define and disseminate processes of care (“Best Practices”) that contribute to improved outcomes for veterans near the end of life and their families.
Progress and next steps
Rollout:» 21 VISNs currently on board
PROMISE website» Methods» FAQs» (Success Stories)
Monthly E-newsletter
PROMISE website:www.cherp.research.va.gov/PROMISE.asp
Find out more about PROMISERegister a QI initiativeRead about others’ success storiesBrag about your own success storyLearn about best practicesJoin a QI collaborative (Carol Luhrs and
Therese Cortez)
